=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528861069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN WILSON LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 03/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 CAMPUS PKWY STE 101
-----------------------------------------------------
City | WALL TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-6841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-924-5589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 BRETONIAN DR
-----------------------------------------------------
City | BRICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08723-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-678-3505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37AC00772000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------